State HIE Strategic and Operational Plan Emerging Models February 16, 2011
Goals and Objectives The State HIE emerging models can be useful in a wide variety of ways, both within the ONC state-level HIE program and beyond it. For states still in the plan approval process, the models highlight approaches that approved plans have used to build on local assets and exchange conditions to enable Stage 1 meaningful use requirements. For states whose plans have been approved, the models can provide valuable perspective for the ongoing refinement and phasing of their approaches. For all states, the models can expedite the process for revision, review and technical assistance for state HIE plans. For sub-state exchanges, providers, provider organizations, and commercial vendors, the models can provide frameworks and strategies to help shape their own HIE plans and investments. For researchers and industry analysts, the models can provide evaluation frameworks to support study and analysis of the successes and challenges of emerging models. 2
State HIE Promising Practices State plans approved to date display many common promising practices: Focus on gap-filling strategies that rapidly enable providers to achieve meaningful use. Recognize and leverage existing assets within the state, including REC, Beacon, existing regional/community efforts, etc. Take a viable and incremental approach, phasing services over time. Monitor for change and adapt over time to respond to stakeholder needs and the evolving market. Support the little guy such as critical access hospitals, rural clinics, and independent labs so that each can support providers in meeting meaningful use. Leverage the market. 3
Scope and Assumptions Based only on currently approved models. The models are based on the patterns observed in state plans that have been approved at the time of analysis. The models may shift or new models may emerge over time. Models are illustrative constructs, not exact descriptions. Some states are highlighted to showcase key elements of each of the models, and it should be noted that no model completely describes any particular grantee or set of grantees. Models are tools, not answers. The models serve only as a guide to highlight common practices and approaches among approved plans. A successful approach in any state will be one that is viable and achievable for the local characteristics of the state. ONC does not approve or recommend any particular model. The models are merely reflections of what exists in the approved plans today and are provided simply as a tool for plan development and refinement. Adopting a particular model or amalgam of models does not guarantee ONC approval of a plan or plan refinement. Every model can stand on its own. None of the models or approaches is favored over another, nor is there any assumption that the models represent stages of maturity or levels of progression. 4
State HIE Strategic and Operational Plan Emerging Models Elevator Capacity-builder Orchestrator Public Utility $ $ Rapid facilitation of directed exchange capabilities to support Stage 1 meaningful use Bolstering of sub-state exchanges through financial and technical support, tied to performance goals Thin-layer state-level network to connect existing sub-state exchanges Statewide HIE activities providing a wide spectrum of HIE services directly to end-users and to substate exchanges where they exist Preconditions: Preconditions: Preconditions: Preconditions: Little to no exchange activity Many providers and data trading partners that have limited HIT capabilities If HIE activity exists, no cross entity exchange Sub-state nodes exist, but capacity needs to be built to meet Stage 1 MU Nodes are not connected No existing statewide exchange entity Operational sub-state nodes Nodes are not connected No existing statewide exchange entity Diverse local HIE approaches Operational state-level entity Strong stakeholder buy-in State government authority/financial support Existing staff capacity 5
Key Model Description Contents Description/ Key Principles Preconditions Organization Technical Legal/policy What approach is being used to accelerate meaningful use achievement and reach HIE program goals? Which environmental features are associated with different program approaches? Who will support state-level infrastructure and services? Who bears responsibility for end-user support? How will end-users that currently do not use HIE services offered by another entity (sub-state node, etc.) be addressed? How will providers/data trading partners that have limited HIT capabilities by supported? What technical architecture supports the model? What services will be centrally deployed at the state-level and what will be local? How will the implementation be phased? What legal and policy foundation is needed to support the model? Risks What are the main risks associated with the model? What mitigation strategies can help minimize risks? Key success factors What are the key organizational, technical, and legal factors that can contribute to ultimate success when using the model? 6
Elevator Preconditions Organization Technical Legal/policy Risks Key success factors Rapid facilitation of directed exchange capabilities to support Stage 1 meaningful use May include limited to no HIE activity in the state or large portions of the state Sometimes a high degree of providers and data suppliers with limited HIT capabilities May include high-level of capability within but not across sub-state networks Partner with vendors to rapidly develop directed exchange (e.g. Direct when available) Work with REC to put boots-on-the-ground to assist providers and data trading partners with limited HIT capabilities with obtaining directed exchange services Enable HISP services to complement privately-developed HISP services and promote commercial retail service penetration as rapidly as possible Initial phase includes promotion of directed exchange services Includes services such as provider directories or certificate authority where they could lower cost or improve services of vendor-supplied directed exchange solutions Future phase may include more robust, modular state-level shared services; may transition to Public Utility or Orchestrator model Minimal requirements for legal/policy infrastructure during phase 1 Refinement of legal/policy framework when state moves to more robust exchange to meet Stage 2 and 3 MU May not lay foundation for cost-effective approach to Stage 2/3 MU May lead to heterogeneity in services, service levels, pricing, etc. that undercut effectiveness or efficiency of other activities such as public health Coordination with REC or others to provide on-the-ground support to providers/data trading partners with limited HIT capabilities Strategy to support more advanced HIE methods and meeting later stages of MU 7
Capacity-builder Preconditions Organization Technical Legal/policy Risks Key success factors Bolstering of sub-state exchanges through financial and technical support, tied to performance goals Multiple sub-state nodes that cover large portion of state in various stages of development Near-operational sub-state nodes have momentum but require assistance to become fully operational State-sponsored grants program to help sub-state nodes fill capability gaps or to address needs of stakeholders with limited HIT capabilities Leverage sub-state nodes to assure access for providers not affiliated with a sub-state node or white space Could issue RFP to procure services to cover un-tethered providers/white space Phase 1 includes development and implementation of funding program (creation of eligibility criteria, review and section process, and program monitoring and evaluation) Phase 2 may transition to Orchestrator model providing thin backbone of state-level shared services to facilitate node-to-node exchange and other value-added services Messaging/routing, provider directory, security services NWHIN, MPI/RLS Policies/procedures to address funding program requirements, including performance goals Dependency on sub-state nodes for state-level sustainability Potential lack of coverage for un-tethered providers/white space Potential for heterogeneity in HIE across state (service levels, pricing, etc.) Strategy to support un-tethered providers/white space Strong coordination including program monitoring, management and remediation to ensure funding program success 8
Orchestrator Preconditions Organization Technical Legal/policy Risks Key success factors Thin-layer state-level network to connect existing sub-state exchanges Multiple nodes of exchange cover large portion of state High level of operational exchange within nodes but little across nodes Strong backing by state government and/or strong stakeholder buy-in Criteria to define, monitor, enforce qualified organizations for state-level exchange Strategy to connect end-users not affiliated with a sub-state exchange or white space may leverage sub-state nodes Does not typically include state-level service provision to end-users directly, only through sub-state networks Phase 1 includes focus on directed exchange (push) to connect sub-state networks in alignment with Stage 1 MU requirements Messaging hub, security services, provider directory Phase 2 may include expansion of core infrastructure to support query/retrieve (pull) of patient data and other value-added services such as data aggregation, analytics, or patient access to information according to market demand and buy-in Light layer state-level policy infrastructure to allow minimum necessary alignment for statewide exchange Dependency on sub-state nodes for state-level sustainability Potential lack of coverage of un-tethered providers/white space Potential for heterogeneity in HIE across state(service levels, pricing, etc.) Strong public-private collaboration with actively engaged state government Development of certification/accreditation processes for sub-state exchange participation in state-level network 9
Public Utility Preconditions Organization Statewide HIE activities providing a wide spectrum of HIE services directly to end-users and to sub-state exchanges where they exist Operational statewide entity/exchange already covering large portion of state Strong backing by state government and strong stakeholder buy-in Well-developed HIE legal or policy infrastructure State-level entity implementation responsibility to connect stakeholders (end-users and sub-state networks as they exist) to state-level infrastructure Close coordination with REC to provide technical assistance to end-users Established staff manages day-to-day operations of state-level infrastructure/services Technical Legal/policy Risks Key success factors Phase 1 includes connecting stakeholders to existing infrastructure and enhancements to support Stage 1 MU May include provisioning of end-user applications and other services such as hosting, training, help-desk Phase 2 includes expansion of core infrastructure to support query/retrieve access to longitudinal care record, connection to NWHIN, consumer access (PHRs), etc. Statewide policy framework relatively well-developed including consent, auditing, and other privacy/security policies Reliance on single organization and infrastructure single-point of failure Requires high level of policy, business, organizational, and technical infrastructure that takes adequate time and resources to fully implement Development and maintenance of full-service organization to meet demands of model Boots-on-the-ground support to assist end-users Strong public-private collaboration with actively engaged state government 10
Approved State Plans by Model WA MT ND MN OR ID WY SD IA WI MI NY VT NH MA ME AK CA NV UT AZ CO NM NE KS OK TX MO AR LA IL MS IN KY TN AL OH GA WV SC PA DC VA NC MD CT DE NJ RI HI FL U.S Territories: American Samoa Guam Northern Mariana Islands Puerto Rico Virgin Islands Elevator Capacity-builder Orchestrator Public Utility **Please note that most grantees display characteristics of more than one model 11
Putting Models into Practice Using the State HIE emerging models for technical assistance can help: States in the planning phase Determine if any model or models may work well in their current HIE environment Address key success factors and risks States in the implementation phase Look for ways to improve current implementation plans Moving from one model to another (if necessary and appropriate) States in the evaluation phase Assess whether key goals and objectives have been obtained and make adjustments as necessary 12
Questions and Discussion 13